From the Guidelines
Tranexamic acid (TXA) should be administered at a loading dose of 1 g infused over 10 minutes, followed by an intravenous infusion of 1 g over 8 h, as this regimen has been shown to reduce mortality due to bleeding in trauma patients 1. The current dosing of 650mg 2 tabs TID is not in line with the most recent and highest quality evidence, which recommends a loading dose and infusion as stated above. Key points to consider when administering TXA include:
- Early administration is crucial, with the best outcomes seen when TXA is given within 1 hour of injury 1
- The risk of death due to bleeding is significantly reduced with TXA, and there is no evidence that the effect of TXA on death due to bleeding varies by systolic blood pressure, Glasgow coma score, or type of injury 1
- TXA should be administered to all patients with trauma and significant bleeding, not just those with major hemorrhage 1
- The use of ε-aminocaproic acid is a potential alternative to TXA if TXA is not available, but it is 10-fold weaker and must be administered by continuous infusion 1 When adjusting TXA dosing, it is essential to monitor the patient's bleeding pattern to ensure adequate control is maintained. However, the most critical factor is to administer TXA as early as possible, and the recommended dosing regimen should be followed to maximize its effectiveness in reducing morbidity, mortality, and improving quality of life.
From the FDA Drug Label
• Reduce the dosage for patients with renal impairment. (2.2,8.6) The FDA drug label does not answer the question.
From the Research
Dosing of Tranexamic Acid (TXA) for Heavy Bleeding
- The standard dose of TXA is often considered to be 1g intravenously in an adult patient, which has been shown to have maximal efficacy without increased risk of thrombotic events 2.
- High-dose TXA, such as 650mg 2 tabs TID, may not provide additional benefits and could potentially increase the risk of adverse events, including deep venous thrombosis, pulmonary embolism, and seizures 3.
- Low-dose IV or enteral TXA may be effective in reducing hemorrhage and rebleeding, with moderate certainty, but more evidence is required to demonstrate its safety 3.
- The optimal dose of TXA may vary depending on the clinical context, and further studies are needed to understand the mechanisms by which TXA provides benefit and to determine the optimal modes of administration and dosing 4, 2, 3.
Considerations for Decreasing the Dose of TXA
- Decreasing the dose of TXA from 650mg 2 tabs TID may be considered, especially if the patient is at risk of adverse events or if the bleeding is not severe.
- However, the decision to decrease the dose should be made on a case-by-case basis, taking into account the individual patient's risk factors and the clinical context 4, 2, 3.
- It is essential to weigh the potential benefits of TXA against the potential risks and to monitor the patient closely for any adverse events 4, 2, 3.